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Olivas I, Cobreros M, Londoño MC, Díaz-González Á. Budesonide in the first line treatment of patients with autoimmune hepatitis. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:561-570. [PMID: 34923033 DOI: 10.1016/j.gastrohep.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/12/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
Budesonide is a glucocorticoid characterized by its local action, with a low systemic bioavailability. Since the original trial comparing budesonide with prednisone in 2010, it is recommended as an effective alternative for the treatment of non-severe acute or chronic autoimmune hepatitis. In this document, we review the general pharmacologic properties of glucocorticoids, the available evidence for the use of budesonide as first line option for autoimmune hepatitis as well as the safety profile of the drug.
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Affiliation(s)
- Ignasi Olivas
- Liver Unit. Hospital Clínic of Barcelona. Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBERehd. Universitat de Barcelona, Barcelona, Spain
| | - Marina Cobreros
- Digestive Diseases Department. Marqués de Valdecilla University Hospital. Instituto de investigación sanitaria Valdecilla (IDIVAL), Santander, Spain
| | - María-Carlota Londoño
- Liver Unit. Hospital Clínic of Barcelona. Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBERehd. Universitat de Barcelona, Barcelona, Spain
| | - Álvaro Díaz-González
- Digestive Diseases Department. Marqués de Valdecilla University Hospital. Instituto de investigación sanitaria Valdecilla (IDIVAL), Santander, Spain
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Graziano EJ, Vaughn BP, Wang Q, Chow LS, Campbell JP. Microscopic Colitis Is Not an Independent Risk Factor for Low Bone Density. Dig Dis Sci 2021; 66:3542-3547. [PMID: 33063187 DOI: 10.1007/s10620-020-06651-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/01/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Microscopic colitis (MC) is a subtype of inflammatory bowel disease (IBD) with overlapping risk factors for low bone density (LBD). While LBD is a known complication of IBD, its association with MC is not well-established. AIMS Assess the prevalence of LBD in MC compared to control populations, and evaluate if MC predicts LBD when controlling for confounders. METHODS Retrospective, observational case control study of adult patients with pathologically confirmed MC from 2005 to 2015. Bone density measurements were abstracted from dual-energy X-ray absorptiometry (DEXA) reports, and bone density was classified using T-score: normal (T ≥ - 1.0), osteopenia (- 1.0 > T > -2.5) or osteoporosis (T ≤ - 2.5). Demographics, disease, medication history and LBD risk factors were obtained from chart review. Prevalence of LBD was compared to national and local controls. A matched control cohort to MC patients without prior diagnosis of LBD was analyzed with logistic regression to assess the relationship of MC to LBD. RESULTS One hundred and eighteen patients with MC were identified. Osteopenia in women with MC was more prevalent compared to national controls (67% vs. 49%, p = 0.0004), and LBD was more prevalent in MC patients compared to local controls (82% vs. 55%, p < 0.0001). In MC patients without prior diagnosis of LBD matched to controls, there was a higher prevalence of osteopenia (53.2% vs. 36.7%, p = 0.04). However, after controlling for confounders, MC was not associated with LBD (OR 0.83, 95% CI 0.22, 3.16, p = 0.8). CONCLUSIONS While LBD was more prevalent in MC patients compared to control populations, with adjustment for key confounders (including BMI, steroids, smoking, vitamin D and calcium use), MC was not an independent predictor of LBD.
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Affiliation(s)
- Elliot J Graziano
- Department of Internal Medicine, University of Minnesota, 420 Delaware Street SE MMC 284, Minneapolis, MN, 55455, USA.
| | - Byron P Vaughn
- Inflammatory Bowel Disease Program, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Lisa S Chow
- Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, MN, USA
| | - James P Campbell
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
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Miehlke S, Guagnozzi D, Zabana Y, Tontini GE, Kanstrup Fiehn A, Wildt S, Bohr J, Bonderup O, Bouma G, D'Amato M, Heiberg Engel PJ, Fernandez‐Banares F, Macaigne G, Hjortswang H, Hultgren‐Hörnquist E, Koulaouzidis A, Kupcinskas J, Landolfi S, Latella G, Lucendo A, Lyutakov I, Madisch A, Magro F, Marlicz W, Mihaly E, Munck LK, Ostvik A, Patai ÁV, Penchev P, Skonieczna‐Żydecka K, Verhaegh B, Münch A. European guidelines on microscopic colitis: United European Gastroenterology and European Microscopic Colitis Group statements and recommendations. United European Gastroenterol J 2021; 9:13-37. [PMID: 33619914 PMCID: PMC8259259 DOI: 10.1177/2050640620951905] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Microscopic colitis is a chronic inflammatory bowel disease characterised by normal or almost normal endoscopic appearance of the colon, chronic watery, nonbloody diarrhoea and distinct histological abnormalities, which identify three histological subtypes, the collagenous colitis, the lymphocytic colitis and the incomplete microscopic colitis. With ongoing uncertainties and new developments in the clinical management of microscopic colitis, there is a need for evidence-based guidelines to improve the medical care of patients suffering from this disorder. METHODS Guidelines were developed by members from the European Microscopic Colitis Group and United European Gastroenterology in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists, pathologists and basic scientists, and voted upon using the Delphi method. RESULTS These guidelines provide information on epidemiology and risk factors of microscopic colitis, as well as evidence-based statements and recommendations on diagnostic criteria and treatment options, including oral budesonide, bile acid binders, immunomodulators and biologics. Recommendations on the clinical management of microscopic colitis are provided based on evidence, expert opinion and best clinical practice. CONCLUSION These guidelines may support clinicians worldwide to improve the clinical management of patients with microscopic colitis.
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Rojo E, Casanova MJ, Gisbert J. Treatment of microscopic colitis: the role of budesonide and new alternatives for refractory patients. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 112:53-58. [PMID: 31880163 DOI: 10.17235/reed.2019.6655/2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Microscopic colitis is a common cause of chronic watery diarrhea with a great impact on patient quality of life. Microscopic colitis includes two histological subtypes: collagenous colitis and lymphocytic colitis. Due to the increasing incidence and awareness of this disease over the last decades, several international guidelines have been recently published. However, there is still significant heterogeneity in the management of these patients, and treatments without solid scientific evidence support are often used in clinical practice. This article reviews the therapeutic role of budesonide in microscopic colitis and summarizes the current evidence regarding other treatments available for this disease, especially for the management of refractory patients. Finally, an updated treatment algorithm is proposed.
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Affiliation(s)
- Eukene Rojo
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, España
| | - María José Casanova
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, España
| | - Javier Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, España
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Dorrington AM, Selinger CP, Parkes GC, Smith M, Pollok RC, Raine T. The Historical Role and Contemporary Use of Corticosteroids in Inflammatory Bowel Disease. J Crohns Colitis 2020; 14:1316-1329. [PMID: 32170314 DOI: 10.1093/ecco-jcc/jjaa053] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of corticosteroids to treat patients with inflammatory bowel disease [IBD] has been the bedrock of IBD therapeutics since the pioneering work of Truelove and Witts in the UK in the 1950s and subsequent large cohort studies in the USA and Europe. Nevertheless, although effective for induction of remission, these agents do not maintain remission and are associated with a long list of recognised side effects, including a risk of increased mortality. With the arrival of an increasing number of therapies for patients with IBD, the question arises as to whether we are using these agents appropriately in contemporary practice. This review discusses the historical background to steroid usage in IBD, and also provides a brief review of the literature on side effects of corticosteroid treatment as relevant to IBD patients. Data on licensed medications are presented with specific reference to the achievement of corticosteroid-free remission. We review available international data on the incidence of corticosteroid exposure and excess, and discuss some of the observations we and others have made concerning health care and patient-level factors associated with the risk of corticosteroid exposure, including identification of 'at-risk' populations.
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Affiliation(s)
- Alexander M Dorrington
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Gareth C Parkes
- Department of Gastroenterology, Royal London Hospital, Barts Health, London, UK
| | - Melissa Smith
- Department of Gastroenterology, Brighton and Sussex University Hospitals, Brighton, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Reilev M, Hallas J, Thomsen Ernst M, Nielsen GL, Bonderup OK. Long-term oral budesonide treatment and risk of osteoporotic fractures in patients with microscopic colitis. Aliment Pharmacol Ther 2020; 51:644-651. [PMID: 32003028 DOI: 10.1111/apt.15648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/05/2019] [Accepted: 01/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Due to a substantial first-pass metabolism of oral budesonide, systemic bioavailability is low compared to other oral corticosteroids, thereby possibly avoiding adverse effects of systemic corticosteroid use. AIM To determine whether use of oral budesonide is associated with osteoporotic fractures in patients with microscopic colitis (MC). METHODS Applying data from the Danish nationwide health registries, we conducted a case-control study nested within a cohort of patients with MC from 2004 to 2012. We estimated odds ratios (ORs) for the association between budesonide use and osteoporotic fractures (hip, wrist and spinal fractures). RESULTS We identified 417 cases with a first occurrence of an osteoporotic fracture. Eighty-six per cent were women and the median age was 78 years. The OR for the overall association between ever-use of budesonide and any osteoporotic fractures did not reach statistical significance (OR 1.13, CI: 0.88-1.47). The highest risk was observed for spinal fractures (OR 1.98, CI: 0.94-4.17), where a dose-response association seemed to exist, followed by hip and wrist fractures (OR 1.17 [CI: 0.79-1.73] and OR 0.99 [CI: 0.66-1.47] respectively). We generally found modestly increased ORs across subgroups at suspected high or low risk of fractures (1.00-2.49). No overall dose-response association was evident (OR for doubling of cumulative dose 0.93 (CI: 0.84-1.03). CONCLUSION No overall association between use of oral budesonide and osteoporotic fractures was demonstrated among individuals with MC. There seemed to be an isolated adverse effect of budesonide on the risk of spinal fractures, which appears to be dose related.
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Affiliation(s)
- Mette Reilev
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Martin Thomsen Ernst
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense University Hospital, Odense, Denmark.,OPEN - Open Patient data Explorative Network, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Gunnar Lauge Nielsen
- Department of Internal Medicine, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ole K Bonderup
- Diagnostic Centre, Regional Hospital Silkeborg, and University Research Clinic for Innovative Patient Pathways, Aarhus University, Aarhus, Denmark
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López-Sanromán A, Clofent J, Garcia-Planella E, Menchén L, Nos P, Rodríguez-Lago I, Domènech E. Reviewing the therapeutic role of budesonide in Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:458-471. [PMID: 30007787 DOI: 10.1016/j.gastrohep.2018.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/03/2018] [Indexed: 10/28/2022]
Abstract
Oral budesonide is a glucocorticoid of primarily local action. In the field of digestive diseases, it is used mainly in inflammatory bowel disease, but also in other indications. This review addresses the pharmacology, pharmacodynamics and therapeutic use of budesonide. Its approved indications are reviewed, as well as other clinical scenarios in which it could play a role, in order to facilitate its use and improve the accuracy of its prescription.
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Affiliation(s)
| | - Joan Clofent
- Servicio de Aparato Digestivo, Hospital de Sagunto, Sagunto, Valencia, España
| | | | | | - Pilar Nos
- Hospital Politècnic La Fe, València, España; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España
| | | | - Eugeni Domènech
- Servei d'Aparell Digestiu, Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
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The association of inflammatory bowel disease and immediate postoperative outcomes following lumbar fusion. Spine J 2018; 18:1157-1165. [PMID: 29155253 PMCID: PMC5953757 DOI: 10.1016/j.spinee.2017.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/16/2017] [Accepted: 11/02/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT The United States Centers for Disease Control and Prevention estimates the prevalence of inflammatory bowel disease (IBD) at more than 3.1 million people. As diagnostic techniques and treatment options for IBD improve, the prevalence of IBD is expected to increase. For spine surgeons, patients with IBD have a unique complication profile because patients with IBD may present with poor nutritional status and because the medications used to manage IBD have been associated with poor vertebral bone mineralization and immunosuppression. Presently, there are very limited data regarding perioperative outcomes among patients with IBD who undergo spinal surgery. The present study begins to address this knowledge gap by describing trends in patients with IBD undergoing lumbar fusion and by quantifying the association between IBD and immediate postoperative outcomes using a large, national database. PURPOSE To advance our understanding of the potential pitfalls and risks associated with lumbar fusion surgery in patients with IBD. DESIGN/SETTING Retrospective cross-sectional analysis. PATIENT SAMPLE The Nationwide Inpatient Sample (NIS) database was queried from 1998 to 2011 to identify adult patients (18+) who underwent primary lumbar fusion operations using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding. OUTCOME MEASURES Incidence of lumbar fusion procedures, prevalence of IBD, complication rates, length of stay, and total hospital charges. METHODS The annual number of primary lumbar fusion operations performed between 1998 and 2011 was obtained from the NIS database. Patients younger than 18 years of age were excluded. The prevalence of IBD in this population (both Crohn disease and ulcerative colitis) was determined using ICD-9-CM codes. Logistic regression models were estimated to determine the association between IBD and the odds of postoperative medical and surgical complications, while controlling for patient demographics, comorbidity burden, and hospital characteristics. The complex survey design of the NIS was taken into account by clustering on hospitals and assuming an exchangeable working correlation using the discharge weights supplied by the NIS. We accounted for multiple comparisons using the Bonferroni correction and an alpha level for statistical significance of . 0028. RESULTS The prevalence of IBD is increasing among patients undergoing lumbar fusion, from 0.21% of all patients undergoing lumbar fusion in 1998 to 0.48% of all patients undergoing lumbar fusion in 2011 (p<.001). The odds of experiencing a postoperative medical or surgical complication were not significantly different when comparing patients with IBD with control patients without IBD after controlling for patient demographics, comorbidity burden, and hospital characteristics (adjusted odds ratio=1.1, 95% confidence interval [CI] 0.99-1.3, p=.08). On multivariable analysis, the presence of IBD in patients undergoing lumbar fusion surgery was associated with longer length of stay and greater hospitalization charges. CONCLUSIONS Among patients who underwent lumbar fusion, IBD is a rare comorbidity that is becoming increasingly more common. Importantly, patients with IBD were not at increased risk of postoperative complications. Spine surgeons should be prepared to treat more patients with IBD and should incorporate the present findings into preoperative risk counseling and patient selection.
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Kuenzig ME, Rezaie A, Kaplan GG, Otley AR, Steinhart AH, Griffiths AM, Benchimol EI, Seow CH. Budesonide for the Induction and Maintenance of Remission in Crohn's Disease: Systematic Review and Meta-Analysis for the Cochrane Collaboration. J Can Assoc Gastroenterol 2018; 1:159-173. [PMID: 30656288 PMCID: PMC6328928 DOI: 10.1093/jcag/gwy018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Budesonide is an oral glucocorticoid designed for the treatment of inflammatory bowel disease (IBD) that may reduce systemic adverse events (AEs). This review examined the efficacy and safety of budesonide for the induction and maintenance of clinical remission in Crohn’s disease (CD). Methods MEDLINE, EMBASE, other electronic databases, reference lists and conference proceedings were searched to November 2017 to identify randomized controlled trials of budesonide. Outcomes were the induction and maintenance of remission at eight weeks and one year, respectively, as well as corticosteroid-related AEs and abnormal adrenocorticotropic hormone (ACTH) tests. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were estimated using random effects models. Results Thirteen induction and 10 maintenance trials were included. Budesonide 9 mg/day was more effective than placebo (RR 1.93; 95% CI, 1.37–2.73; GRADE: moderate) but less effective than conventional steroids (RR 0.85; 95% CI, 0.75–0.97; GRADE: moderate) to induce remission. Corticosteroid-related AEs occurred less often with induction doses of budesonide than steroids (RR 0.64; 95% CI, 0.54–0.76; GRADE: moderate); budesonide did not increase AEs relative to placebo (RR 0.97; 95% CI, 0.76–1.23; GRADE: moderate). Budesonide 6 mg/day was not different from placebo for maintaining remission (RR 1.13; 95% CI, 0.94–1.35; GRADE: moderate). Both induction (GRADE: low for 3 mg/day, moderate for 9 mg/day) and maintenance budesonide treatment (GRADE: very low for 3 mg/day, low for 6 mg/day) increased the risk of an abnormal ACTH test compared with placebo, but less than conventional steroids (GRADE: very low for both induction and maintenance). Conclusion For induction of clinical remission, budesonide was more effective than placebo, but less effective than conventional steroids. Budesonide was not effective for the maintenance of remission. Budesonide was safer than conventional steroids, but the long-term effects on the adrenal axis and bone health remain unknown.
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Affiliation(s)
- M Ellen Kuenzig
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology & Nutrition, Children’s Hospital of Eastern Ontario, Ontario, Ottawa, Canada
| | - Ali Rezaie
- Department of Medicine, Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Anthony R Otley
- Division of Gastroenterology, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - A Hillary Steinhart
- Department of Medicine, Division of Gastroenterology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne Marie Griffiths
- Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric I Benchimol
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology & Nutrition, Children’s Hospital of Eastern Ontario, Ontario, Ottawa, Canada
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Correspondence: Cynthia H. Seow, 3280 Hospital Drive NW, TRW building, Rm 6D18, Calgary, AB, T2N 4Z6, Canada, e-mail
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Bezzio C, Festa S, Zerboni G, Papi C, Manes G, Saibeni S. A safety evaluation of budesonide MMX for the treatment of ulcerative colitis. Expert Opin Drug Saf 2018; 17:437-444. [DOI: 10.1080/14740338.2018.1442432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Cristina Bezzio
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Garbagnate Milanese, Italy
| | | | | | - Claudio Papi
- IBD Unit, San Filippo Neri Hospital, Rome, Italy
| | - Gianpiero Manes
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Garbagnate Milanese, Italy
| | - Simone Saibeni
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Garbagnate Milanese, Italy
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Fernandez-Bañares F, Piqueras M, Guagnozzi D, Robles V, Ruiz-Cerulla A, Casanova MJ, Gisbert JP, Busquets D, Arguedas Y, Pérez-Aisa A, Fernández-Salazar L, Lucendo AJ. Collagenous colitis: Requirement for high-dose budesonide as maintenance treatment. Dig Liver Dis 2017; 49:973-977. [PMID: 28457904 DOI: 10.1016/j.dld.2017.03.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/20/2017] [Accepted: 03/31/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Controlled studies show high efficacy of budesonide in inducing short-term clinical remission in collagenous colitis (CC), but relapses are common after its withdrawal. AIM To evaluate the need for high-dose budesonide (≥6mg/d) to maintain clinical remission in CC. METHODS Analysis of a multicentre retrospective cohort of 75 patients with CC (62.3±1.5years; 85% women) treated with budesonide in a clinical practice setting between 2013 and 2015. Frequency of budesonide (9mg/d) refractoriness and safety, and the need for high-dose budesonide to maintain clinical remission, were evaluated. Drugs used as budesonide-sparing, including azathioprine and mercaptopurine, were recorded. Logistic regression analysis was performed to evaluate the risk factors associated with the need for high-dose budesonide (≥6mg/d) to maintain clinical remission. RESULTS Budesonide induced clinical remission in 92% of patients, with good tolerance. Fourteen of 68 patients (21%; 95% CI, 13-32%) needed high-dose budesonide to maintain remission. Only intake of NSAIDs at diagnosis (OR, 8.6; 95% CI, 1.6-44) was associated with the need for high-dose budesonide in the multivariate analysis. TREATMENT with thiopurines was effective in 5 out of 6 patients (83%; 95% CI, 44-97%), allowing for withdrawal from or a dose decrease of budesonide. CONCLUSIONS One fifth of CC patients, especially those with NSAID intake at diagnosis, require high-dose budesonide (≥6mg/d) to maintain clinical remission. In this setting, thiopurines might be effective as budesonide-sparing drugs.
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Affiliation(s)
- Fernando Fernandez-Bañares
- University Hospital Mutua Terrassa; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas.
| | - Marta Piqueras
- Consorci Sanitari Terrassa, Department of Gastroenterology, Terrassa, Spain
| | - Danila Guagnozzi
- Hospital Vall d'Hebron, Department of Gastroenterology, Barcelona, Spain
| | - Virginia Robles
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas; Hospital Vall d'Hebron, Department of Gastroenterology, Barcelona, Spain
| | | | - María José Casanova
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas; University Hospital La Princesa
| | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas; University Hospital La Princesa
| | | | - Yolanda Arguedas
- Hospital San Jorge, Department of Gastroenterology, Huesca, Spain
| | | | | | - Alfredo J Lucendo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas; Hospital General of Tomelloso
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Abstract
INTRODUCTION Ulcerative colitis (UC) is a chronic inflammatory bowel disease with a relapsing-remitting course that determines significant morbidity and can associate with local complications and/or extra-intestinal manifestations. Pharmacological therapies are often required for a lifetime with possible risks of toxicity and side effects. Areas covered: Non-biological therapies (i.e. aminosalicylates, corticosteroids and immunosuppressive drugs) are widely used in UC patients for controlling the active phases of the disease and maintaining remission. Expert Opinion: Aminosalycilates have a good safety profile with a low risk of idiosyncrasic reactions. In contrast, the use of corticosteroids and immunosuppressive drugs can associate with unacceptable side effects, some of which are potentially life threatening. Mechanisms underlying the development of these side effects are not fully understood and strategies aimed to prevent them have not yet been standardized. However, clinicians should monitor the patients during therapy to recognize the adverse events at an early stage of the occurrence. New drugs that selectively target molecules involved in the amplification of the ongoing mucosal inflammation are currently under investigation. Preliminary data indicate that such compounds have better overall safety and tolerability than corticosteroids and immunosuppressive drugs.
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Affiliation(s)
- Edoardo Troncone
- a Department of Systems Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Giovanni Monteleone
- a Department of Systems Medicine , University of Rome "Tor Vergata" , Rome , Italy
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Abstract
BACKGROUND AND AIMS The prevalence and incidence of inflammatory bowel disease (IBD) in North America is among the highest in the world and imparts substantial direct and indirect medical costs. The Choosing Wisely Campaign was launched in wide variety of medical specialties and disciplines to reduce unnecessary or harmful tests or treatment interventions. METHODS The Choosing Wisely list for IBD was developed by the Canadian IBD Network for Research and Growth in Quality Improvement (CINERGI) in collaboration with Crohn's and Colitis Canada (CCC) and the Canadian Association of Gastroenterology (CAG). Using a modified Delphi process, 5 recommendations were selected from an initial list of 30 statements at a face-to-face consensus meeting. RESULTS The 5 things physicians and patients should question: (1) Don't use steroids (e.g., prednisone) for maintenance therapy in IBD; (2) Don't use opioids long-term to manage abdominal pain in inflammatory bowel disease (IBD); (3) Don't unnecessarily prolong the course of intravenous corticosteroids in patients with acute severe ulcerative colitis (UC) in the absence of clinical response; (4) Don't initiate or escalate long-term medical therapies for the treatment of IBD based only on symptoms; and (5) Don't use abdominal computed tomography (CT) scan to assess IBD in the acute setting unless there is suspicion of a complication (obstruction, perforation, abscess) or a non-IBD etiology for abdominal symptoms. CONCLUSIONS The Choosing Wisely recommendations will foster patient-physician discussions to optimize IBD therapy, reduce adverse effects from testing and treatment, and reduce medical expenditure.
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Biancone L, Annese V, Ardizzone S, Armuzzi A, Calabrese E, Caprioli F, Castiglione F, Comberlato M, Cottone M, Danese S, Daperno M, D'Incà R, Frieri G, Fries W, Gionchetti P, Kohn A, Latella G, Milla M, Orlando A, Papi C, Petruzziello C, Riegler G, Rizzello F, Saibeni S, Scribano ML, Vecchi M, Vernia P, Meucci G, Bossa F, Cappello M, Cassinotti A, Chiriatti A, Fiorino G, Formica V, Guidi L, Losco A, Mocciaro F, Onali S, Pastorelli L, Pica R, Principi M, Renna S, Ricci C, Rispo A, Rogai F, Sarmati L, Scaldaferri F, Spina L, Tambasco R, Testa A, Viscido A. Safety of treatments for inflammatory bowel disease: Clinical practice guidelines of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD). Dig Liver Dis 2017; 49:338-358. [PMID: 28161290 DOI: 10.1016/j.dld.2017.01.141] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 12/19/2016] [Accepted: 01/07/2017] [Indexed: 02/08/2023]
Abstract
Inflammatory bowel diseases are chronic conditions of unknown etiology, showing a growing incidence and prevalence in several countries, including Italy. Although the etiology of Crohn's disease and ulcerative colitis is unknown, due to the current knowledge regarding their pathogenesis, effective treatment strategies have been developed. Several guidelines are available regarding the efficacy and safety of available drug treatments for inflammatory bowel diseases. Nevertheless, national guidelines provide additional information adapted to local feasibility, costs and legal issues related to the use of the same drugs. These observations prompted the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) to establish Italian guidelines on the safety of currently available treatments for Crohn's disease and ulcerative colitis. These guidelines discuss the use of aminosalicylates, systemic and low bioavailability corticosteroids, antibiotics (metronidazole, ciprofloxacin, rifaximin), thiopurines, methotrexate, cyclosporine A, TNFα antagonists, vedolizumab, and combination therapies. These guidelines are based on current knowledge derived from evidence-based medicine coupled with clinical experience of a national working group.
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Affiliation(s)
- Livia Biancone
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy.
| | - Vito Annese
- AOU Careggi, Gastroenterology, Florence, Italy
| | - Sandro Ardizzone
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco - University of Milan, Milan, Italy
| | - Alessandro Armuzzi
- IBD Unit, Presidio Columbus, Fondazione Policlinico Gemelli Universita' Cattolica, Rome, Italy
| | - Emma Calabrese
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy
| | - Flavio Caprioli
- Department of Pathophysiology and Transplantation, University of Milan and Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda,Ospedale Policlinico di Milano, Milan, Italy
| | | | - Michele Comberlato
- Department of Gastroenterology and Digestive Endoscopy, Central Hospital, Bolzano, Italy
| | - Mario Cottone
- Division of Internal Medicine 2, IBD Unit, Hospital "Riuniti Villa Sofia-Cervello", Palermo, Italy
| | - Silvio Danese
- Humanitas Research Hospital and Humanitas University, Rozzano (Milan), Italy
| | - Marco Daperno
- Hospital "Ordine Mauriziano di Torino", Turin, Italy
| | - Renata D'Incà
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Italy
| | - Giuseppe Frieri
- University of L'Aquila, Gastroenterology Unit, L'Aquila, Italy
| | - Walter Fries
- Department of Clinical and Experimental Medicine, Clinical Unit for Chroric Bowel Disorders, University of Messina, Messina, Italy
| | - Paolo Gionchetti
- IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Anna Kohn
- San Camillo-Forlanini Hospital, IBD Unit, Rome, Italy
| | | | | | - Ambrogio Orlando
- Division of Internal Medicine 2, IBD Unit, Hospital "Riuniti Villa Sofia-Cervello", Palermo, Italy
| | - Claudio Papi
- IBD Unit, San Filippo Neri Hospital, Rome, Italy
| | - Carmelina Petruzziello
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy
| | - Gabriele Riegler
- U.O. of Gastroenterology C.S. - University della Campania "Luigi Vanvitelli", Naples, Italy
| | - Fernando Rizzello
- IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Simone Saibeni
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Rho, Italy
| | | | - Maurizio Vecchi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato and University of Milan, San Donato Milanese, Milan, Italy
| | - Piero Vernia
- Gastroenterology Unit, Sapienza, University of Rome, Rome, Italy
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Wolf JL. Unmasking the Impact of Gender on Inflammatory Bowel Disease. WOMENS HEALTH 2016; 1:299-303. [DOI: 10.2217/17455057.1.3.299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Jacqueline L Wolf
- Beth Israel Deaconess Medical Center, Division of Gastroenterology, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA, Tel.: +1 617 667 4241; Fax: +1 617 667 1071
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Challenges in the Diagnosis and Management of Inflammatory Bowel Disease in the Elderly. ACTA ACUST UNITED AC 2015; 13:275-86. [DOI: 10.1007/s11938-015-0059-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Saibeni S, Meucci G, Papi C, Manes G, Fascì-Spurio F. Low bioavailability steroids in inflammatory bowel disease: an old chestnut or a whole new ballgame? Expert Rev Gastroenterol Hepatol 2014; 8:949-62. [PMID: 24882015 DOI: 10.1586/17474124.2014.924396] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
At present, therapy of inflammatory bowel disease is still far from being fully satisfactory; old drugs like steroids, for instance, still represent a cornerstone in the treatment of active disease despite their associated important side effects and incomplete clinical efficacy. In the last years, new therapeutic strategies have been suggested in order to avoid or at least limit steroids use and in this direction the so-called low bioavailability steroids appeared to be a promising therapeutic weapon; however, some grey areas about their real utility and manner of use still remain. The aim of this review is to evaluate the available evidence about the use of oral budesonide and beclomethasone dipropionate in inflammatory bowel disease, to critically assess their current position in the therapeutic algorithm of these diseases and to give simple and practical indications for their use in every-day clinical practice.
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Affiliation(s)
- Simone Saibeni
- U.O. Gastroenterologia, Ospedale di Rho, Azienda Ospedaliera G. Salvini, Corso Europa 250, 20017, Rho (MI), Italy
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Kuenzig ME, Rezaie A, Seow CH, Otley AR, Steinhart AH, Griffiths AM, Kaplan GG, Benchimol EI. Budesonide for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2014; 2014:CD002913. [PMID: 25141071 PMCID: PMC7133546 DOI: 10.1002/14651858.cd002913.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Corticosteroids are effective for induction, but not maintenance of remission in Crohn's disease. Significant concerns exist regarding the risk for adverse events, particularly when corticosteroids are used for long treatment courses. Budesonide is a glucocorticoid with limited systemic bioavailability due to extensive first-pass hepatic metabolism and is effective for induction of remission in Crohn's disease. OBJECTIVES To evaluate the efficacy and safety of oral budesonide for maintenance of remission in Crohn's disease. SEARCH METHODS The following databases were searched from inception to 12 June 2014: PubMed, MEDLINE, EMBASE, CENTRAL, the Cochrane IBD/FBD Group Specialised Trial Register, and ClinicalTrials.gov. Reference lists of articles, as well as conference proceedings were manually searched. SELECTION CRITERIA Randomized controlled trials comparing budesonide to a control treatment, or comparing two doses of budesonide, were included. The study population included patients of any age with quiescent Crohn's disease. DATA COLLECTION AND ANALYSIS Two independent investigators reviewed studies for eligibility, extracted data and assessed study quality using the Cochrane risk of bias tool. The primary outcome was maintenance of remission at various reported follow-up times during the study. Secondary outcomes included: time to relapse, mean change in CDAI, clinical, histological, improvement in quality of life, adverse events and study withdrawal. We calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for dichotomous outcomes and the mean difference (MD) and 95% CI for continuous outcomes. Data were analysed on an intention-to-treat basis. The Chi(2) and I(2) statistics were used to assess heterogeneity. Random-effects models were used to allow for expected clinical and statistical heterogeneity. The overall quality of the evidence supporting the primary outcome was assessed using the GRADE criteria. MAIN RESULTS Twelve studies (n = 1273 patients) were included in the review: eight studies compared budesonide to placebo, one compared budesonide to 5-aminosalicylates, one compared budesonide to traditional systemic corticosteroids, one compared budesonide to azathioprine, and one compared two doses of budesonide. Nine studies used a controlled ileal release form of budesonide, while three used a pH-modified release formulation. Nine studies were judged to be at low risk of bias. Three studies were judged to be at high risk of bias due to blinding and one of these studies also had inadequate allocation concealment. Budesonide 6 mg daily was no more effective than placebo for maintenance of remission at 3 months, 6 months or 12 months. At three months 64% of budesonide 6 mg patients remained in remission compared to 52% of placebo patients (RR 1.25, 95% CI 1.00 to 1.58; 6 studies, 540 patients). A GRADE analysis indicated that the overall quality of the evidence for this outcome was low due to moderate heterogeneity (I(2) = 56%) and sparse data (315 events). At six months 61% of budesonide 6 mg patients remained in remission compared to 52% of placebo patients (RR 1.15, 95% CI 0.95 to 1.39; 5 studies, 420 patients). A GRADE analysis indicated that the overall quality of the evidence for this outcome was moderate due to sparse data (238 events). At 12 months 55% of budesonide 6 mg patients remained in remission compared to 48% of placebo patients (RR 1.13; 95% CI 0.94 to 1.35; 5 studies, 420 patients). A GRADE analysis indicated that the overall quality of the evidence for this outcome was moderate due to sparse data (215 events). Similarly, there was no significant benefit for budesonide 3 mg compared to placebo at 6 and 12 months. There was no statistically significant difference in continued remission at 12 months between budesonide and weaning doses of prednisolone (RR 0.79; 95% CI 0.55 to 1.13; 1 study, 90 patients). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was low due to sparse data (51 events) and high risk of bias (no blinding). Budesonide 6 mg was better than mesalamine 3 g/day at 12 months (RR 2.51, 95% CI 1.03 to 6.12; 1 study, 57 patients). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was very low due to very sparse data (18 events) and high risk of bias (no blinding). There was no statistically significant difference in continued remission at 12 months between budesonide and azathioprine (RR 0.81; 95% CI 0.61 to 1.08; 1 study 77 patients). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was very low due to sparse data (55 events) and high risk of bias (single-blind and no allocation concealment). The use of budesonide 6 mg resulted in slight improvements in CDAI scores when assessed at 6 months (MD -24.30, 95% CI -46.31 to -2.29) and 12 months (MD -23.49, 95% CI -46.65 to -0.32) and mean time to relapse of disease (MD 59.93 days, 95% CI 19.02 to 100.84). Mean time to relapse was significantly shorter for patients receiving budesonide than for those receiving azathioprine (MD -58.00, 95% CI -96.68 to -19.32). Adverse events were not more common in patients treated with budesonide compared to placebo (6 mg: RR 1.51, 95% CI 0.90 to 2.52; 3 mg: RR 1.19, 95% CI 0.63 to 2.24). These events were relatively minor and did not result in increased rates of study withdrawal. Commonly reported treatment-related adverse effects included acne, moon facies, hirsutism, mood swings, insomnia, weight gain, striae, and hair loss. Abnormal adrenocorticoid stimulation tests were seen more frequently in patients receiving both 6 mg (RR 2.88, 95% CI 1.72 to 4.82) and 3 mg daily (RR 2.73, 95% CI 1.34 to 5.57) compared to placebo. AUTHORS' CONCLUSIONS These data suggest budesonide is not effective for maintenance of remission in CD, particularly when used beyond three months following induction of remission. Budesonide does have minor benefits in terms of lower CDAI scores and longer time to relapse of disease. However, these benefits are offset by higher treatment-related adverse event rates and more frequent adrenocorticoid suppression in patients receiving budesonide.
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Affiliation(s)
- M Ellen Kuenzig
- The Children's Hospital of Eastern OntarioDivision of Gastroenterology Hepatology & Nutrition401 Smyth RoadOttawaONCanadaK1H 8L1
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Ali Rezaie
- Cedars‐Sinai Medical CenterDepartment of MedicineLos AngelesCaliforniaUSA90048
| | - Cynthia H Seow
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
- University of CalgaryDepartment of MedicineTRW Building Rm 6D183280 Hospital Drive NWCalgaryABCanadaT2N 4Z6
| | - Anthony R Otley
- IWK Health CentreHead, Division of Gastroenterology5850 University AvenueHalifaxNSCanadaB3K 6R8
| | - A. Hillary Steinhart
- Mount Sinai HospitalDepartment of Medicine, Division of GastroenterologyRoom 445, 600 University AvenueTorontoONCanadaM5G 1X5
| | - Anne Marie Griffiths
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology & Nutrition555 University Ave.TorontoONCanadaM5G 1X8
| | - Gilaad G Kaplan
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
- University of CalgaryDepartment of MedicineTRW Building Rm 6D183280 Hospital Drive NWCalgaryABCanadaT2N 4Z6
| | - Eric I Benchimol
- The Children's Hospital of Eastern OntarioDivision of Gastroenterology Hepatology & Nutrition401 Smyth RoadOttawaONCanadaK1H 8L1
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Abstract
PURPOSE OF REVIEW To provide a synopsis on established and new research evaluating bone disease in patients with inflammatory bowel disease (IBD). RECENT FINDINGS Persons with IBD, including Crohn's disease and ulcerative colitis are believed to be at high risk for osteoporosis and fracture. As osteoporosis is clinically silent and persons with IBD are not universally screened, the burden of bone disease in IBD has been difficult to accurately assess. It is also unclear whether bone disease is due to inflammatory activity, medication use, poor nutrient intake/absorption, or body habitus characteristics. Recent studies using population-wide databases of bone mineral density (BMD) analyses suggest that Crohn's disease is responsible for a small effect on BMD after adjusting for other risk factors for low BMD, whereas ulcerative colitis does not appear to confer an independent risk. Furthermore, IBD does not appear to be a risk for overall fracture once controlling for factors which are associated with both IBD and fracture risk. The ability to assess BMD on incidentally performed computed tomography scans may allow detection of low BMD in IBD patients. SUMMARY Although reduced BMD and fracture are more common in persons with IBD, the precise burden is not well characterized. Also, the relative impact of IBD-associated factors and IBD-specific inflammation on bone health is still uncertain.
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Prantera C, Scribano ML. Budesonide multi-matrix system formulation for treating ulcerative colitis. Expert Opin Pharmacother 2014; 15:741-3. [PMID: 24484392 DOI: 10.1517/14656566.2014.884072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Budesonide is a corticosteroid characterized by high topical activity and low systemic effect associated with fewer glucocorticoid-related adverse events than conventional steroids. Differently from Crohn's disease, no evidence suggests that oral budesonide is effective for the induction of remission of ulcerative colitis (UC). Budesonide multi-matrix (MMX) system is a new oral preparation that, by employing a MMX, provides the release of the drug throughout the entire colon. Its efficacy in inducing UC remission, at a dose of 9 mg, is based on some recent trials. However, in two studies the absolute differences between budesonide MMX and placebo were much lower than the rate of success reported in previous trials with mesalazines. In addition, the therapeutic advantage of budesonide MMX 9 mg over 5-aminosalicylic acid (5-ASA) showed by one study, and the advantage of budesonide MMX over budesonide reported in the other study, was only 5.8 and 4.8%, respectively. The evidence supporting the use of budesonide MMX at a dose of 6 mg for maintenance is weak. Therefore, the effective dosage should be 9 mg also in maintenance, but not for > 4 - 6 months, because a prolonged treatment has showed to increase the rate of side effects.
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Affiliation(s)
- Cosimo Prantera
- Gastroenterology Unit, Azienda Ospedaliera San Camillo-Forlanini , Circonvallazione Gianicolense, 87 - 00152 Rome , Italy +39 6 3202643 ; +39 6 3202643 ;
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Prantera C, Marconi S. Glucocorticosteroids in the treatment of inflammatory bowel disease and approaches to minimizing systemic activity. Therap Adv Gastroenterol 2013; 6:137-56. [PMID: 23503968 PMCID: PMC3589135 DOI: 10.1177/1756283x12473675] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel diseases (IBDs) are a group of inflammatory conditions characterized by chronic, uncontrolled inflammation of the gastrointestinal tract. Reported prevalence is high in the United States and northern Europe, while the incidence varies greatly across the rest of Europe. Glucocorticosteroids are the standard treatment for IBD, but due to adverse events their use can be limited. However, new formulations of glucocorticosteroids have been developed to reduce systemic activation. The aim of this review was to assess and summarize the efficacy and safety of new formulations of glucocorticosteroids. A MEDLINE search identified publications focused on new formulations of nonsystemic steroid-based drugs for IBD and benefits and limitations of each of the new glucocorticosteroid formulations were identified. Budesonide has good efficacy and is an established treatment for Crohn's disease; it has been shown to be beneficial for the induction of remission in these patients, although it is not recommended for the maintenance of induced remission. Glucocorticosteroids are not recommended for the maintenance of remission in patients with IBD. However, a recent study suggested that beclomethasone dipropionate may be effective for prolonged treatment in patients in the postacute phase of Crohn's disease who were treated with a short course of systemic steroids. The efficacy of fluticasone propionate and prednisolone metasulphobenzoate in IBD is not well established given the small number of patients enrolled in the few published clinical trials. While the tolerability of these glucocorticosteroids is favourable, more research comparing these new agents with traditional systemic glucocorticosteroids is warranted.
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Affiliation(s)
- Cosimo Prantera
- Azienda Ospedaliera San Camillo Forlanini, via Monterosi 116, 00191 Rome, Italy
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Ye BD, Yang SK, Shin SJ, Lee KM, Jang BI, Cheon JH, Choi CH, Kim YH, Lee H. [Guidelines for the management of Crohn's disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 59:141-79. [PMID: 22387837 DOI: 10.4166/kjg.2012.59.2.141] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease (IBD) with uncertain etiopathogenesis. CD can involve any site of gastrointestinal tract from the mouth to anus and is associated with serious complications such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower than those of Western countries, but have been rapidly increasing during the past decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies are currently applied for diverse clinical situations of CD. However, a lot of decisions on the management of CD are made depending on the personal experiences and choices of physicians. To suggest preferable approaches to diverse problems of CD and to minimize the variations according to physicians, guidelines for the management of CD are needed. Therefore, IBD Study Group of the Korean Association for the Study of the Intestinal Diseases has set out to develop the guidelines for the management of CD in Korea. These guidelines were developed using the adaptation methods and encompass the treatment of inflammatory disease, stricturing disease, and penetrating disease. The guidelines also cover the indication of surgery, prevention of recurrence after surgery, and CD in pregnancy and lactation. These are the first Korean guidelines for the management of CD and the update with further scientific data and evidences is needed.
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Affiliation(s)
- Byong Duk Ye
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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The immunopathogenesis of celiac disease reveals possible therapies beyond the gluten-free diet. Semin Immunopathol 2012; 34:581-600. [DOI: 10.1007/s00281-012-0318-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/04/2012] [Indexed: 12/18/2022]
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Leib ES, Saag KG, Adachi JD, Geusens PP, Binkley N, McCloskey EV, Hans DB. Official Positions for FRAX(®) clinical regarding glucocorticoids: the impact of the use of glucocorticoids on the estimate by FRAX(®) of the 10 year risk of fracture from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX(®). J Clin Densitom 2011; 14:212-9. [PMID: 21810527 DOI: 10.1016/j.jocd.2011.05.014] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 05/21/2011] [Indexed: 12/16/2022]
Abstract
Given the significant impact the use of glucocorticoids can have on fracture risk independent of bone density, their use has been incorporated as one of the clinical risk factors for calculating the 10-year fracture risk in the World Health Organization's Fracture Risk Assessment Tool (FRAX(®)). Like the other clinical risk factors, the use of glucocorticoids is included as a dichotomous variable with use of steroids defined as past or present exposure of 3 months or more of use of a daily dose of 5 mg or more of prednisolone or equivalent. The purpose of this report is to give clinicians guidance on adjustments which should be made to the 10-year risk based on the dose, duration of use and mode of delivery of glucocorticoids preparations. A subcommittee of the International Society for Clinical Densitometry and International Osteoporosis Foundation joint Position Development Conference presented its findings to an expert panel and the following recommendations were selected. 1) There is a dose relationship between glucocorticoid use of greater than 3 months and fracture risk. The average dose exposure captured within FRAX(®) is likely to be a prednisone dose of 2.5-7.5 mg/day or its equivalent. Fracture probability is under-estimated when prednisone dose is greater than 7.5 mg/day and is over-estimated when the prednisone dose is less than 2.5 mg/day. 2) Frequent intermittent use of higher doses of glucocorticoids increases fracture risk. Because of the variability in dose and dosing schedule, quantification of this risk is not possible. 3) High dose inhaled glucocorticoids may be a risk factor for fracture. FRAX(®) may underestimate fracture probability in users of high dose inhaled glucocorticoids. 4) Appropriate glucocorticoid replacement in individuals with adrenal insufficiency has not been found to increase fracture risk. In such patients, use of glucocorticoids should not be included in FRAX(®) calculations.
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Affiliation(s)
- Edward S Leib
- University of Vermont College of Medicine, Burlington, Vermont, USA.
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Abstract
Adolescents with anorexia nervosa (AN) are at risk for low bone mass at multiple sites, associated with decreased bone turnover. Bone microarchitecture is also affected, with a decrease in bone trabecular volume and trabecular thickness, and an increase in trabecular separation. The adolescent years are typically the time when marked increases occur in bone mass accrual towards the attainment of peak bone mass, an important determinant of bone health and fracture risk in later life. AN often begins in the adolescent years, and decreased rates of bone mass accrual at this critical time are therefore also concerning for deficits in peak bone mass. Factors contributing to low bone density and decreased rates of bone accrual include alterations in body composition such as low body mass index and lean body mass, and hormonal alterations such as hypogonadism, a nutritionally acquired resistance to GH and low levels of IGF-I, relative hypercortisolemia, low levels of leptin, and increased adiponectin (for fat mass) and peptide YY. Therapeutic strategies include optimizing weight and menstrual recovery, and adequate calcium and vitamin D replacement. Oral estrogen-progesterone combination pills are not effective in increasing bone density in adolescents with AN. Recombinant human IGF-I increases levels of bone formation markers in the short term, while long-term effects remain to be determined. Bisphosphonates act by decreasing bone resorption, and are not optimal for use in adolescents with AN, in whom the primary defect is low bone formation.
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Affiliation(s)
- M Misra
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Abstract
GOAL The goal of this study is to evaluate the safety and efficacy of Small intestinal release mesalamine (SIRM) for symptom relief in refractory celiac disease (RCD). BACKGROUND Therapeutic options for the RCD are inadequate and treatment with corticosteroids and immunosuppressants is limited by side effects. SIRM has been shown to have local antiinflammatory action and excellent tolerability. STUDY We reviewed records of the RCD patients who received SIRM in an open-label therapeutic trial. Data included demographics, disease characteristics, dose and duration of SIRM therapy, and response. Response was categorized as complete if there was complete resolution of symptoms, partial if there was at least 50% improvement, and nonresponsive if there was less than 50% improvement. RESULTS Four patients were treated with SIRM alone and 6 received SIRM and oral budesonide. Within 4 weeks, 50% had complete response and an additional 10% had partial response. Two of the 6 patients were able to discontinue budesonide. One patient discontinued SIRM owing to headaches. CONCLUSION SIRM seems to be a safe and efficacious treatment option in patients with RCD. Larger, controlled trials of this agent are warranted.
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Dignass A, Van Assche G, Lindsay JO, Lémann M, Söderholm J, Colombel JF, Danese S, D'Hoore A, Gassull M, Gomollón F, Hommes DW, Michetti P, O'Morain C, Oresland T, Windsor A, Stange EF, Travis SPL. The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Current management. J Crohns Colitis 2010; 4:28-62. [PMID: 21122489 DOI: 10.1016/j.crohns.2009.12.002] [Citation(s) in RCA: 1005] [Impact Index Per Article: 71.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 12/04/2009] [Indexed: 02/08/2023]
Affiliation(s)
- A Dignass
- Department of Medicine I, Markus-Krankenhaus, Wilhelm-Epstein-Str. 4, D-60431 Frankfurt/Main, Germany.
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Bossa F, Colombo E, Andriulli A, Annese V. Treatment of steroid-naive ulcerative colitis. Expert Opin Pharmacother 2009; 10:1449-60. [DOI: 10.1517/14656560902973728] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Misra M, Prabhakaran R, Miller KK, Goldstein MA, Mickley D, Clauss L, Lockhart P, Cord J, Herzog DB, Katzman DK, Klibanski A. Prognostic indicators of changes in bone density measures in adolescent girls with anorexia nervosa-II. J Clin Endocrinol Metab 2008; 93:1292-7. [PMID: 18089697 PMCID: PMC2291487 DOI: 10.1210/jc.2007-2419] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Adolescents with anorexia nervosa (AN) have low bone mineral density (BMD). Baseline predictors of temporal BMD changes (DeltaBMD) in AN, including 1) gastrointestinal peptides regulating food intake and appetite that have been related to bone metabolism and 2) bone turnover markers, have not been well characterized. We hypothesized that baseline levels of nutritionally regulated hormones and of bone turnover markers would predict DeltaBMD overall. METHODS In a prospective observational study, lumbar and whole-body BMD was measured at 0, 6, and 12 months in 34 AN girls aged 12-18 yr and 33 controls. Baseline body mass index, lean mass, nutritionally regulated hormones [IGF-I, cortisol, ghrelin, leptin, and peptide YY (PYY)], bone formation, and resorption markers were examined to determine nutritional and hormonal predictors of bone density changes. RESULTS In a regression model, baseline ghrelin and PYY predicted changes in spine bone measures; and baseline ghrelin, cortisol, and PYY predicted changes in whole-body bone measures independent of baseline nutritional status. CONCLUSIONS Neuroendocrine gastrointestinal-derived peptides regulating food intake are independent predictors of changes in bone mass in AN.
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Affiliation(s)
- Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114, USA.
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Manguso F, Balzano A. Meta-analysis: the efficacy of rectal beclomethasone dipropionate vs. 5-aminosalicylic acid in mild to moderate distal ulcerative colitis. Aliment Pharmacol Ther 2007; 26:21-9. [PMID: 17555418 DOI: 10.1111/j.1365-2036.2007.03349.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Beclomethasone dipropionate (BDP) is a second-generation steroid with topical effects and minimal systemic activity for patients with ulcerative colitis (UC). AIM To review all available literature to assess the efficacy of enema/foam BDP compared with enema/foam 5-aminosalicylic acid (5-ASA) in the control of left-sided mild-moderate UC. METHODS We selected randomized controlled trials of enema/foam BDP compared with enema/foam 5-ASA treatment in patients with UC. Two reviewers assessed trial quality and extracted data independently. RESULTS Four trials involving 428 UC patients, 209 treated with 5-ASA (1-4 g o.d.) and 219 with BDP (3 mg o.d.), were included. Intention-to-treat analysis showed that 5-ASA induced improvement/remission of UC in 146 (69.9%) patients, while BDP in 143 (65.3%). The test for heterogeneity (Cochran Q) was not significant and Mantel-Haenszel pooled estimate of odds ratio was 1.23 (95% CI = 0.82-1.85). The results did not change when analysis was performed on a per-protocol basis. CONCLUSION The randomized controlled trials identified in this review showed that rectal BDP has equal effect as 5-ASA to control symptoms in UC.
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Affiliation(s)
- F Manguso
- Gastroenterology Unit, A. Cardarelli Hospital, Naples, Italy
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Lee N, Fowler E, Mason S, Lincoln D, Taaffe DR, Radford-Smith G. Tumor necrosis factor-alpha haplotype is strongly associated with bone mineral density in patients with Crohn's disease. J Gastroenterol Hepatol 2007; 22:913-9. [PMID: 17565648 DOI: 10.1111/j.1440-1746.2006.04679.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIM There is limited consensus on the major variables that determine bone integrity and bone loss in patients with Crohn's disease. Twin and family studies in the general population indicate that up to 85% of variance in bone mineral density is inherited. The aim was to determine the prevalence of bone loss and both molecular and clinical risk factors for bone loss in a large Crohn's disease population. METHODS This was a cross-sectional study of 304 patients with Crohn's disease attending the Inflammatory Bowel Disease unit at Royal Brisbane and Women's Hospital, Queensland. The results of bone density testing were ascertained directly and by a mailed questionnaire. Bone mineral density data were combined with clinical information and correlated with single nucleotide polymorphisms within the tumor necrosis factor-alpha (TNF-alpha), interleukin-10, and NOD2/CARD15 genes. RESULTS Of 304 Crohn's disease patients, 101 had undergone previous bone density testing. Forty-five patients (45%) had been diagnosed with osteopenia and 18 (18%) were osteoporotic. After multivariate analysis, both the TNF-alpha GT haplotype and the -857 CC genotype showed strong associations with bone mineral density overall (P = 0.003 and P = 0.002, respectively). Body mass index (P = 0.01) and previous bowel resection in female patients (P = 0.03) were predictive of a higher spine bone density, while body mass index (P = 0.003) and the effect of years since first bowel resection (P = 0.02) remained independent predictors of proximal femur bone mineral density. There were no other significant associations observed. CONCLUSIONS This study has identified a novel protective association between a TNF-alpha haplotype and bone mineral density in Crohn's disease. It confirms the important influence of body mass index and intestinal resection on bone loss in this population.
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Affiliation(s)
- Naomi Lee
- School of Human Movement Studies, University of Queensland, Brisbane, Queensland, Australia
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Abstract
Secondary osteoporosis is caused by various non-physiological factors. It affects 5% of all patients with osteoporosis and accounts for 20% of all osteoporotic fractures. Glucocorticoid induced osteoporosis is the most common form of secondary osteoporosis, whereas an endogenous Cushing syndrome rarely results in decreased bone mineral density. In addition, chronic inflammatory diseases which require a glucocorticoid therapy also need to be considered in the context of osteoporosis. This article presents the current data on glucocorticoid induced osteoporosis and an update of the proposed DVO (Dachverbandes Osteologie, umbrella organization of German scientific osteology-related societies) guidelines 2006.
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Affiliation(s)
- U Lange
- Abt. Rheumatologie, Klinische Immunologie, Physikalische Medizin und Osteologie, Kerckhoff-Klinik, Benekestrasse 2-8, 61231 Bad Nauheim.
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Williams SE, Seidner DL. Metabolic bone disease in gastrointestinal illness. Gastroenterol Clin North Am 2007; 36:161-90, viii. [PMID: 17472881 DOI: 10.1016/j.gtc.2007.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Metabolic bone disease is often silent, often undiagnosed, and occurs frequently in patients with chronic gastrointestinal illnesses. Potentially modifiable risk factors, such as malnutrition, malabsorption, prolonged use of glucocorticoids, and a sedentary lifestyle, can lead to low bone mass, an increased rate of bone loss, and debilitating bone disease. This article explores common gastrointestinal illnesses that place patients at risk for developing metabolic bone disease. Concepts are presented to assist the practitioner in identifying patients at risk; clinical evaluation and diagnostic test selection are discussed, and therapeutic options for the prevention and treatment of metabolic bone disease in gastrointestinal illness are presented.
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Affiliation(s)
- Susan E Williams
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, 9500 Euclid Avenue, A 30, Cleveland, OH 44195, USA.
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Pazianas M, Rhim AD, Weinberg AM, Su C, Lichtenstein GR. The effect of anti-TNF-alpha therapy on spinal bone mineral density in patients with Crohn's disease. Ann N Y Acad Sci 2006; 1068:543-56. [PMID: 16831950 DOI: 10.1196/annals.1346.055] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Proinflammatory cytokines, including tumor necrosis factor-alpha (TNF-alpha) might be, at least partially, responsible for the development of osteopenia or osteoporosis in Crohn's disease. We investigated whether anti-TNF therapy for Crohn's disease could have any skeletal impact. Therefore, we studied the effects of infliximab, a monoclonal antibody against TNF-alpha with and without bisphosphonates, on spinal bone mineral density (BMD). The effect of corticosteroids was also analyzed. A retrospective cohort analysis was performed on 61 patients with Crohn's disease and low BMD by serial DXA scans. Twenty-three patients were on infliximab and 36 patients were on bisphosphonates. Mean duration between DXA scans was 2.2 +/- 0.99 years. After controlling for corticosteroid use, patients with concurrent infliximab and bisphosphonate treatment exhibited a greater increase in BMD compared to those on bisphosphonates alone (+6.7%/year vs. +4.46%/year, P= 0.045); corticosteroids inhibited this effect (P= 0.025). However, infliximab alone had no effects on BMD. Patients receiving bisphosphonates showed a significant increase in lumbar spine BMD compared to those not on bisphosphonates (+3.97% change in T score/year vs. -3.68%/year, P < 0.0001). Concurrent corticosteroid use significantly inhibited this effect (+2.15%/year vs. +4.97%/year, P= 0.0014). Concurrent infliximab use may confer an additional benefit to that already documented for bisphosphonate use alone; bisphosphonates are beneficial in the treatment of low BMD in patients with Crohn's disease, though corticosteroids may partially inhibit this effect.
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Affiliation(s)
- Michael Pazianas
- Department of Medicine, University of Pennsylvania, 3615 Chestnut Street, Philadelphia, PA 19104, USA.
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Abstract
Anorexia nervosa (AN), a condition of severe undernutrition, is associated with low bone mineral density (BMD) in adults and adolescents. Whereas adult women with AN have an uncoupling of bone turnover markers with increased bone resorption and decreased bone formation markers, adolescents with AN have decreased bone turnover overall. Possible contributors to low BMD in AN include hypoestrogenism and hypoandrogenism, undernutrition with decreased lean body mass, and hypercortisolemia. IGF-I, a known bone trophic factor, is reduced despite elevated growth hormone (GH) levels, leading to an acquired GH resistant state. Elevated ghrelin and peptide YY levels may also contribute to impaired bone metabolism. Weight recovery is associated with recovery of BMD but this is often partial, and long-term and sustained weight recovery may be necessary before significant improvements are observed. Anti-resorptive therapies have been studied in AN with conflicting results. Oral estrogen does not increase BMD or prevent bone loss in AN. The combination of bone anabolic and anti-resorptive therapy (rhIGF-I with oral estrogen), however, did result in a significant increase in BMD in a study of adult women with AN. A better understanding of the pathophysiology of low BMD in AN, and development of effective therapeutic strategies is critical. This is particularly so for adolescents, who are in the process of accruing peak bone mass, and in whom a failure to attain peak bone mass may occur in AN in addition to loss of established bone.
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Affiliation(s)
- Madhusmita Misra
- Pediatric Endocrine Unit, Massachusetts General Hospital for Children, Boston, MA, USA
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Braun F, Behrend M. Basic immunosuppressive drugs outside solid organ transplantation. Expert Opin Investig Drugs 2006; 15:267-91. [PMID: 16503764 DOI: 10.1517/13543784.15.3.267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Immunosuppressive drugs are the backbone of solid organ transplantation. The introduction of new immunosuppressive drugs led to improved patient and organ survival rates. Nowadays, acute rejection can be reduced to a minimum. Individualization and avoidance of drug-related adverse effects became a new goal to achieve. The potency of immunosuppressive drugs makes them attractive for use in various autoimmune diseases; therefore, the experience on immunosuppressive drugs outside the field of organ transplantation is analysed in this review.
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Affiliation(s)
- Felix Braun
- General and Transplantation Surgery, University of Kiel, Germany
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Abstract
Patients with Crohn's disease are at increased risk of developing disturbances in bone and mineral metabolism because of several factors, including the cytokine-mediated nature of the inflammatory bowel disease, the intestinal malabsorption resulting from disease activity or from extensive intestinal resection and the use of glucucorticoids to control disease activity. Inability to achieve peak bone mass when the disease starts in childhood, malnutrition, immobilization, low BMI, smoking and hypogonadism may also play a contributing role in the pathogenesis of bone loss. The relationship between long-term use of glucocorticoids for any disease indication and increased risk for osteoporosis and fractures is well established. However, the relationship between Crohn's disease and ulcerative colitis and bone loss remains controversial. Depending on the population studied the prevalence of osteoporosis has thus been variably reported to range from 12 to 42% in patients with inflammatory bowel disease (IBD). In IBD most studies demonstrate a negative correlation between bone mineral density (BMD) and glucocorticoid use, but not all authors agree on the relationship between long-term glucocorticoid use and continuing bone loss. Whereas prospective studies do suggest sustained bone loss at both trabecular and cortical sites in long-term glucocorticoid users with inflammatory bowel disease, a decrease in bone mass is also observed in patients with active Crohn's disease not using glucocorticoids, and bone loss is not universally observed in patients with Crohn's disease using orally or rectally administered glucocorticoids. Data on vertebral fractures are scarce and there is no agreement about the risk of non-vertebral fractures in patients with Crohn's disease, although it has been suggested that non-vertebral fracture risk may be increased by up to 60% in patients with IBD. A recent publication reports an increased risk of hip fractures in Crohn's disease related to current and cumulative corticosteroid use and use of opiates, although these fractures could not be related to the severity of osteoporosis. The issue of the magnitude of the problem of osteoporosis has become particularly relevant in Crohn's disease, since the ability of therapeutic interventions to beneficially influence skeletal morbidity has been clearly established in patients with osteoporosis, whether post-menopausal women, men or glucocorticoid users. The main question that arises is whether all patients with Crohn's disease should be treated with bone protective agents on the assumption that they all have the potential to develop osteoporosis or whether the use of these agents should be restricted to patients clearly at risk of osteoporosis and fractures, providing these can be identified. We recommend, based on the available literature and our own experience, that all patients with Crohn's disease should be screened for osteoporosis by means of a bone mineral density measurement in addition to full correction of any potential calcium and vitamin D deficiency, to allow timely therapeutic intervention of the patient at risk while sparing the vast majority unnecessary medical treatment.
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Affiliation(s)
- R A van Hogezand
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands.
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Homan M, Baldassano RN, Mamula P. Managing complicated Crohn's disease in children and adolescents. NATURE CLINICAL PRACTICE. GASTROENTEROLOGY & HEPATOLOGY 2005; 2:572-9. [PMID: 16327836 DOI: 10.1038/ncpgasthep0338] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Accepted: 09/22/2005] [Indexed: 01/05/2023]
Abstract
The natural history of Crohn's disease is characterized by recurrent exacerbations. A small, but significant, number of pediatric patients with Crohn's disease are resistant to standard medical therapies. The goal of therapy in pediatric patients is not only to achieve and maintain clinical remission, but also to promote growth, development and improve quality of life. All of this needs to be achieved within a relatively short window of opportunity, before growth and development deficiencies become permanent. The standard therapy for pediatric patients with Crohn's disease consists of 5-aminosalicylic-acid compounds, antibiotics and enteral nutrition. Enteral nutrition has an excellent adverse-effect profile and, in addition to its therapeutic effect, positively impacts growth and nutritional status. Immunomodulating medications, such as azathioprine, 6-mercaptopurine and methotrexate, are frequently used to maintain remission, and to treat corticosteroid-dependent and perianal disease. Recently, biologic treatment with the anti-tumor-necrosis-factor-alpha antibody infliximab has dramatically changed the therapeutic approach. The long-term safety of this therapy still needs to be established. Limited data are available on other biologic therapies, which, at this point in time, are considered experimental and are only available through clinical trials.
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Affiliation(s)
- Matjaz Homan
- University Pediatric Hospital, Ljubljana, Slovenia
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Abstract
Crohn's disease (CD) is associated with a number of secondary conditions including osteoporosis, which increases the risk of bone fracture. The cause of metabolic bone disease in this population is believed to be multifactorial and may include the disease itself and associated inflammation, high-dose corticosteroid use, weight loss and malabsorption, a lack of exercise and physical activity, and an underlying genetic predisposition to bone loss. Reduced bone mineral density has been reported in between 5% to 80% of CD sufferers, although it is generally believed that approximately 40% of patients suffer from osteopenia and 15% from osteoporosis. Recent studies suggest a small but significantly increased risk of fracture compared with healthy controls and, perhaps, sufferers of other gastrointestinal disorders such as ulcerative colitis. The role of physical activity and exercise in the prevention and treatment of CD-related bone loss has received little attention, despite the benefits of specific exercises being well documented in healthy populations. This article reviews the prevalence of and risk factors for low bone mass in CD patients and examines various treatments for osteoporosis in these patients, with a particular focus on physical activity.
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Affiliation(s)
- Naomi Lee
- School of Human Movement Studies, The University of Queensland, Queensland, Australia
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Abstract
BACKGROUND Corticosteroids continue to play a central role in induction of remission in active Crohn's disease. However, their use comes at a price of significant adverse effects when used repeatedly or for extended periods. Newer corticosteroid agents with limited systemic bioavailability offer a tantalizing option, if they can be shown to be efficacious and safer than conventional corticosteroids. Budesonide is the main alternative corticosteroid currently available in an enteric formulation. OBJECTIVES To evaluate the effectiveness of oral budesonide for the treatment of acute flares of Crohn's disease. A secondary but important endpoint was to evaluate the adverse effect profile. SEARCH STRATEGY The following sources were used to search the literature for potentially relevant papers and trials. 1. A computer-assisted search of the on-line bibliographic database MEDLINE from 1986 onwards. 2. Hand searching the reference lists of trials and review articles identified by means of the computer- assisted search. 3. Proceedings from major gastrointestinal meetings were manually searched from 1990 onwards. 4. Contact with the relevant pharmaceutical companies that have been involved in the development of budesonide. SELECTION CRITERIA Potentially relevant articles were reviewed in an independent unblinded fashion by two authors to determine if they met the criteria specified below: 1) STUDY POPULATION: Patients of any age with acutely active Crohn's disease, as defined by a CDAI > 150. 2) METHODOLOGY: Randomized double blind controlled trials comparing budesonide to a control treatment. Patients in the control arm may have received placebo, conventional corticosteroids, 5-aminosalicylic acid or sulfasalazine. 3) OUTCOME MEASURES: Clinical remission was the outcome measure of interest. The definition of remission was usually a CDAI < 150 by 8 to 16 weeks of therapy. DATA COLLECTION AND ANALYSIS Eligible articles were reviewed in duplicate and the results of the primary research trials were abstracted onto specially designed data extraction forms. The proportion of patients achieving remission in the active treatment and control groups of each study were derived from the data provided in the original research papers. Where possible, data were broken down based on site of disease or other strata used by the individual trials. STATISTICAL ANALYSIS Data extracted from the original research articles were converted, where necessary, into individual 2 x 2 tables (remission versus no remission x budesonide versus control) for each of the individual studies. Where available, individual 2 x 2 tables for strata within studies were also used. The presence of significant heterogeneity among studies was tested for using the chi-square test. Because this is a relatively insensitive test for the presence of heterogeneity, a p-value of 0.10 was regarded as statistically significant. Where p < 0.10 the data from the individual studies were still combined but the pooled results were interpreted with caution. The 2 x 2 tables were synthesized into a summary test statistic using the pooled odds ratio and 95% confidence intervals as described by Cochran and Mantel and Haenszel. A fixed effects model was used for the pooling of data. The analysis was performed initially by combining data from all trials to estimate the response rate to budesonide therapy. The analysis was also performed by combining only studies with comparable control groups. MAIN RESULTS Eight studies were deemed eligible for review. EFFICACY Budesonide was superior to placebo for induction of remission with a pooled odds ratio for the two placebo-controlled trials of 2.85 (95% CI 1.67 - 4.87). A single trial comparing budesonide with mesalamine demonstrated an odds ratio of 2.80 (95% CI 1.50 - 5.20) in favour of budesonide over mesalamine for induction of remission in active Crohn's disease. However, budesonide was inferior to conventional corticosteroids (prednisone or prednisolone) for induction of remission with a pooled odds ratio for the five trials of 0.69 (95% CI 0.51 - 0.95). SAFETY The two trials comparing budesonide versus placebo (Greenberg 1994; Tremaine 2002) showed no difference between study groups for proportion of reported corticosteroid-related adverse effects with the pooled odds ratio for both trials of 0.98 (95% CI 0.58 - 1.67). Five trials comparing budesonide versus prednisone showed the budesonide study group had fewer reported corticosteroid-related adverse effects than the prednisone study group (pooled odds ratio was 0.38 (95% CI 0.28 - 0.53). AUTHORS' CONCLUSIONS With disease in the ileum or ascending colon, budesonide offers an effective therapy which is somewhat less efficacious but with fewer adverse effects than conventional corticosteroids (e.g. prednisone, prednisolone, or 6-methylprednisolone).
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Affiliation(s)
- A Otley
- Dalhousie University, Pediatrics, 5850 University Avenue, Halifax, Nova Scotia, Canada B3H 3T4.
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Bernstein M, Irwin S, Greenberg GR. Maintenance infliximab treatment is associated with improved bone mineral density in Crohn's disease. Am J Gastroenterol 2005; 100:2031-5. [PMID: 16128948 DOI: 10.1111/j.1572-0241.2005.50219.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Diminished bone mineral density (BMD) is a recognized complication of Crohn's disease (CD). The mechanisms underlying bone loss are unclear but may include a direct effect of inflammatory cytokines related to disease activity. Because tumor necrosis factor alpha (TNF-alpha) plays a central role in the pathogenesis of CD inflammation, we evaluated the effect on BMD of maintenance treatment with infliximab in patients with CD. METHODS BMD of the lumbar spine (L2-L4) and proximal left femur (neck and trochanter) were measured at baseline and 1 yr in 46 CD patients treated with infliximab (5 mg/kg) at 6-8 wk intervals for 1 yr. Thirteen patients received concurrent prednisone at a mean dose of 10 mg/day (range: 5-15). RESULTS At baseline, reduced BMD (T-score <or= 1) occurred in 43% of patients at the lumbar spine and 46% at the left femur. Between baseline and 1 yr, mean BMD increased at the lumbar spine by 2.4%+/- 0.7% (p= 0.002), at the femoral trochanter by 2.8%+/- 1.2% (p= 0.03), and at the femoral neck by 2.6%+/- 0.7% (p= 0.001). BMD gain at the lumbar spine and the left femur between the groups without and with osteopenia were not different. Changes in BMD were not correlated with concurrent corticosteroid therapy, calcium supplementation, or changes in C-reactive protein (CRP). CONCLUSIONS Maintenance treatment with infliximab improves BMD in patients with CD and this effect is independent of corticosteroid administration. The BMD response after infliximab suggests that TNF-alpha plays a role in the bone loss associated with CD.
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Affiliation(s)
- Michael Bernstein
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Schoon EJ, Bollani S, Mills PR, Israeli E, Felsenberg D, Ljunghall S, Persson T, Haptén-White L, Graffner H, Bianchi Porro G, Vatn M, Stockbrügger RW. Bone mineral density in relation to efficacy and side effects of budesonide and prednisolone in Crohn's disease. Clin Gastroenterol Hepatol 2005; 3:113-21. [PMID: 15704045 DOI: 10.1016/s1542-3565(04)00662-7] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Osteoporosis frequently occurs in Crohn's disease, often because of corticosteroids. Budesonide as controlled release capsules is a locally acting corticosteroid with low systemic bioavailability. We investigated its effects on bone compared with prednisolone. METHODS In 34 international centers, 272 patients with Crohn's disease involving ileum and/or colon ascendens were randomized to once daily treatment with budesonide or prednisolone for 2 years at doses adapted to disease activity. One hundred eighty-one corticosteroid-free patients had active disease (98 had never received corticosteroids, corticosteroid naive; 83 had received corticosteroids previously, corticosteroid exposed), and 90 had quiescent disease, receiving long-term low doses of corticosteroids, corticosteroid-dependent; in 1 patient, no efficacy data were obtained. Bone mineral density and fractures were assessed in a double-blinded fashion; disease activity, side effects, and quality of life were monitored. RESULTS Neither the corticosteroid-free nor the corticosteroid-dependent patients treated with budesonide differed significantly in bone mineral density from those receiving prednisolone. However, corticosteroid-naive patients receiving budesonide had smaller reductions in bone mineral density than those on prednisolone (mean, -1.04% vs -3.84%; P = .0084). Treatment-emergent corticosteroid side effects were less frequent with budesonide. Efficacy was similar in both groups. CONCLUSIONS Treatment with budesonide is associated with better preserved bone mass compared with prednisolone in only the corticosteroid-naive patients with active ileocecal Crohn's disease. In both the corticosteroid-free and corticosteroid-dependent groups, budesonide and prednisolone were equally effective for up to 2 years, but budesonide caused fewer corticosteroid side effects.
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Affiliation(s)
- Erik J Schoon
- Department of Gastroenterology, University Hospital Maastricht, The Netherlands
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Abstract
Corticosteroids are a mainstay in the treatment of inflammatory bowel disease. Administered topically, orally, or intravenously corticosteroids rapidly and consistently improve moderate to severe active ulcerative colitis and Crohn's disease, although they are ineffective in the maintenance of remission in either illness. The beneficial effects of corticosteroid therapy are counterbalanced by their many side effects. A better understanding of the mechanism of steroid action and toxicity has led to the development of novel corticosteroids that offer the promise of continued efficacy with minimal toxicity. This article reviews the role of conventional and novel corticosteroids in the management of inflammatory bowel disease.
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Affiliation(s)
- Jeffry A Katz
- Division of Gastroenterology, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA.
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Abstract
Osteoporosis is associated with a high morbidity rate and is a risk factor for fractures. Patients with inflammatory bowel disease are at increased risk of developing osteopenia and osteoporosis. Corticosteroid use, malnutrition, and proinflammatory cytokines are unique risk factors for bone loss in ulcerative colitis and Crohn disease. Bone mineral density is assessed by dual-energy X-ray absorptiometry and reported as a T score or number of standard deviations away from the mean. A T score < 1 SD below the mean is normal, 1 to 2.5 SD below the mean is consistent with osteopenia, and greater than 2.5 SD below the mean is defined as osteoporosis. Treatment includes a combination of basic preventative measures, for example, weight-bearing exercise, calcium, vitamin D, and pharmacologic agents, (e.g., bisphosphonates).
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Affiliation(s)
- Manisha Harpavat
- Inflammatory Bowel Disease Program, Children's Hospital of Pittsburgh, Division of Pediatric Gastroenterology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15212, USA
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Jahnsen J, Falch JA, Mowinckel P, Aadland E. Bone mineral density in patients with inflammatory bowel disease: a population-based prospective two-year follow-up study. Scand J Gastroenterol 2004; 39:145-53. [PMID: 15000276 DOI: 10.1080/00365520310007873] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bone loss and osteoporosis are commonly reported in inflammatory bowel disease (IBD), especially Crohn disease (CD). The aims of the present study were to evaluate changes in bone mineral density (BMD) in IBD patients during a 2-year follow-up period, and to investigate the role played by possible contributing factors in bone loss. METHODS Sixty patients with CD and 60 with ulcerative colitis (UC) were studied initially. Fifty-five CD and 43 UC patients were re-examined after 1 year, and 50 CD and 44 UC patients after 2 years. Lumbar spine, femoral neck and total body BMD were measured by dual X-ray absorptiometry (DXA), and Z scores were obtained by comparison with age-matched and sex-matched healthy subjects. Biochemical variables were assessed at inclusion and at the 1-year follow-up visit. RESULTS Mean BMD values were unchanged in both CD and UC patients. In patients with repeated measurements, significant differences in Z scores (delta Z score) were found for femoral neck and total body in CD and for total body in UC. Significant bone loss occurred in 11 CD (22%) and 12 UC (27%) patients. A significant increase in BMD was found in 21 CD (42%) and 20 UC (46%) patients. In CD patients the initial BMD values for lumbar spine and femoral neck were inversely correlated to BMD changes at the same sites and the change in body mass index (BMI) was positively correlated to change in the total body BMD. C-reactive protein was significantly higher in CD patients with bone loss. Biochemical markers of bone metabolism could not be used to predict BMD changes. Although it was not significant, there was a relationship between corticosteroid therapy and bone loss in CD. CONCLUSIONS Only minor changes in BMD were observed in both CD and UC patients during a 2-year period. The multifactorial pathogenesis of bone loss in IBD makes it difficult to assess the importance of each single contributing factor. However, our results indicate that disease activity and corticosteriod therapy are involved in bone loss in CD patients.
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Affiliation(s)
- J Jahnsen
- Medical Dept. and Hormone Laboratory, Aker University Hospital, Oslo, Norway.
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von Tirpitz C, Epp S, Klaus J, Mason R, Hawa G, Brinskelle-Schmal N, Hofbauer LC, Adler G, Kratzer W, Reinshagen M. Effect of systemic glucocorticoid therapy on bone metabolism and the osteoprotegerin system in patients with active Crohn's disease. Eur J Gastroenterol Hepatol 2003; 15:1165-70. [PMID: 14560148 DOI: 10.1097/00042737-200311000-00003] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Osteoporosis may occur in 25-30% of patients with Crohn's disease. Its pathogenesis is not completely understood. Both systemic inflammation in acute disease and treatment with systemic glucocorticoids have been implicated. The aim of the present study was to investigate changes in bone density and biochemical markers of bone metabolism before and during a 3-month period of high-dose glucocorticoid treatment for acute flare-up of Crohn's disease. METHODS Twenty-five patients with active Crohn's disease requiring systemic glucocorticoid treatment (prednisolone, 60 mg/day) were investigated. Lumbar spine and femoral neck bone mineral densitometry was performed at baseline and again after 3 months. Clinical examinations including evaluation of the Crohn's disease activity index and measurement of the biochemical markers osteocalcin, deoxypyridinoline, osteoprotegerin and the soluble receptor activator of NF-kappaB ligand were performed prior to, and at 1, 2 and 12 weeks following steroid administration. RESULTS Median lumbar bone mineral density decreased significantly during the observation period by 1.04% from -0.84 (t score; range, -2.8 to +0.57) to -0.95 (range, -3.1 to +0.40; P = 0.022), while bone density of the total femur decreased by 2.9% from -0.83 (range, -2.61 to +1.86) to -0.90 (range, -2.65 to +0.19; P = 0.01). Serum levels of osteocalcin, a bone formation marker, and osteoprotegerin, an anti-resorptive cytokine produced by osteoblasts, decreased after the first 2 weeks of treatment and reached baseline levels after 3 months. No significant change was found for the bone resorption marker deoxypyridinoline, while soluble receptor activator of NF-kappaB ligand, a cytokine promoting bone resorption, tended to increase during steroid treatment. CONCLUSION A decrease in bone mineral density in patients with Crohn's disease appears to result, at least in part, from a short-term effect of systemic glucocorticoid. Modulation of osteoclastogenesis by the receptor activator of NF-kappaB ligand/osteoprotegerin cytokine system and decreased osteoblastic function may be the underlying molecular basis.
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Abstract
OBJECTIVE To review the pharmacology, pharmacokinetics, efficacy, and safety of oral budesonide (Entocort EC) in the treatment of mild to moderate Crohn's disease (CD). DATA SOURCES The MEDLINE database (1966-December 2002) was searched using the key words budesonide and inflammatory bowel diseases and restricted to the English language. The references from relevant articles were also reviewed for additional citations. STUDY SELECTION AND DATA EXTRACTION Articles and abstracts that evaluated oral budesonide for management of CD were considered, with emphasis on randomized, controlled clinical trials. DATA SYNTHESIS Budesonide's high potency at the glucocorticoid receptor and extensive first-pass hepatic metabolism result in a topical antiinflammatory effect on intestinal tissue, with minimal systemic glucocorticoid adverse effects. Clinical trials have demonstrated that budesonide is effective in the treatment of patients with mild to moderate CD of the ileum and ascending colon, with efficacy similar to prednisolone and superior to mesalamine. Long-term therapy with budesonide increased the duration of CD remission, but the effect was not sustained up to 1 year. Budesonide failed to prevent postsurgical relapse of CD. Adrenal suppression and glucocorticoid-related adverse effects have been reported at lower rates in patients treated with budesonide compared with prednisolone. Patients prescribed budesonide should be monitored for hepatic dysfunction and potential drug interactions. CONCLUSIONS Budesonide is an effective and relatively safe option for treatment of mild to moderate CD of the ileum and ascending colon.
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Affiliation(s)
- Kristi N Hofer
- Department of Pharmacy Services, University of Virginia Health System, PO Box 800674, Charlottesville, VA 22908-0674, USA.
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